Royal Lancaster Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This meant we looked for evidence that people were protected from abuse and avoidable harm. We assessed 8 quality statements.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected when this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed, but we saw improvements had been made. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

However, medicines were not always managed well and the paediatric department was not secure or staffed well. Areas on the corridor used as temporary escalation spaces for patients were not always suitable due to the width of the corridor and promoting patient dignity. The service was still in breach of the legal regulation in relation to safe care and treatment and staffing.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. We scored the service

All staff we spoke with could articulate what constituted an incident and how they would report it. Staff were encouraged by senior leaders to report incidents as the department promoted a no blame culture and told us incidents were essential for learning.

The trust used an electronic system for the reporting of incidents. Incidents graded as moderate or above need to have duty of candour applied and indicated where external reporting was also required. Staff understood the duty of candour. There was a “Being Open” policy that set out the trust’s responsibilities requiring health care professionals to inform patients about actions which have resulted in harm.

Learning from incidents was shared in staff meetings and daily huddles held throughout each day. Staff also received feedback from investigation of incidents such as in monthly ‘learning to improve’ posters or case studies. Minutes and actions from review of incident meetings were available to staff electronically.

We reviewed all incidents and saw a wide range of issues being reported. Between 10 June 2024 to 10 June 2025 the trust reported 1,459 events relating to urgent and emergency care, the majority of which (73%) were reported as incidents, 27% were reported as risks and less than 1% were reported as outcomes. The main themes reported were unsafe staffing (with particular reference to lack of paediatric nursing on several occasions), overcrowded departments/high level of high acuity patients and long waits.

The trust reported one never event in urgent and emergency care in November 2024 at Lancaster Royal Infirmary and was reported as wrong site surgery.

We saw examples of learning from incidents. This included the introduction of a system that would allow patients who struggled to wait in crowded environments to wait elsewhere and to be notified of when to return for assessment which minimised the time in department and alleviated anxiety. These patient’s were given an alerting device that buzzed when it was time to return to the department.

Staff were debriefed and received support after serious incidents were reported. As well as internal debrief sessions, occupational health services were also available for staff support.

Risks were managed by senior leaders within the department and all senior leaders could articulate the highest risks in the department. The highest risk at time of the inspection was overcrowding in the department and a lack of escalation space. We saw some mitigation in the introduction of new streaming pathways to relieve the pressure on the department but at the time of inspection these were not fully embedded.

We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff learnt from incidents and complaints as all information was shared by senior leaders. We saw examples of service users being listened to and their views being taken into account.

All staff that we spoke with were able to articulate the complaints process and how they would facilitate patients making a complaint. We noted that staff would proactively request feedback and that equal importance was given to both positive and negative issues. We noted multiple examples of information regarding the complaints process distributed across the department. We also noted that the department was introducing a ’15 steps for paediatrics’ to ensure that the paediatric patient voice was heard.

We reviewed five complaints received by the department and found that all were managed appropriately and were investigated, actions identified and responded to within the appropriate timescale. Where learning was identified, actions were shared with staff.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Between July 2024 and June 2025, there was a total of 51,646 attendances to the emergency department. Of these, 44,269 were adults and 7,377 were children. For the minor treatment unit (MTU), over the same time period, there were 13,388 attendances of which 10,104 were adults and 3,284 were children. There had been a steady increase in attendances from the previous year.

The trust consistently reported a shorter or similar median time from arrival to treatment compared to the England average from April 2023 to February 2025. In March 2025 the trust reported its worst median time to treatment across the reporting period at 68 minutes which demonstrated patients were waiting longer to be treated. The trust was not meeting the national standard.

On arrival to the emergency department, patients who self-attended were booked into the department by a receptionist who passed the details to a senior nurse for review and allocated patients to the most appropriate area.

Patients who were directed or ‘streamed’ to the emergency department were triaged by trained staff using the Manchester triage system (MTS). There was support from a senior doctor or clinician who could assess patients and refer directly to clinical specialties. Staff told us that there were pathways to stream patients directly to specialty assessment areas in the hospital, but there were inconsistencies as when the specialties would accept the patients. When the department was busy, patients did experience a delay being reviewed by specialty doctors and leaders were aware of this.

We observed ambulance handovers for two patients and saw that staff assisted patients with transfers from the ambulance stretcher; patients were offered pain relief medicine on arrival and appropriate assessments and observations were undertaken. We observed a child who presented with family members in severe pain. The child was immediately taken into the paediatric part of the emergency department for care and treatment.

The service had 24-hour access to specialist mental health support. Patients who presented with a mental health concern, were referred to the mental health liaison team (MHLT) from the local NHS mental health trust to review the patient in the department. Referral was by phone with an expectation that patients would be reviewed within the hour. Emergency department staff were responsible for completing regular observations of patients until they were transferred onwards. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions.

Dependent on their presenting conditions, patients were streamed daily to the minor treatment unit, acute frailty unit, priority assessment and discharge unit and the same day emergency care units (SDEC) that were open between 8am and 10pm. This also helped with flow through the main ED.

There was a discharge co-ordinator who monitored patients through the department. Safety huddles were scheduled four times daily at 9.15am, 2pm, 6pm and 10pm. Huddles were multidisciplinary that included representatives from medicine, paediatrics, orthopaedics and the priority assessment and discharge unit (PADU) as well as bed managers.

Site team huddles took place at 9.30am, 12.30pm, 4pm and 19.45pm. We observed the huddles and how the team worked together to support patient flow through the department, however staff fed back that wards were not always proactive with discharge planning that meant patients spent a longer time in the department. Leaders told us that this had been raised with trust leaders who were looking at options to support.

We did not see any allied health professionals (AHP’s) such as physiotherapists and occupational therapists in the department, other than the pharmacy team. Following the on-site inspection, we received feedback that some AHP staff felt underutilised in supporting doctors with treatment and rehabilitation of patients both in the department and in the minor treatment unit (MTU). This meant that timely specialist support for patients could potentially be delayed.

Electronic discharge summaries were completed which contained all relevant information about the patients stay in the department when they were discharged home.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained to the appropriate safeguarding role for their level. Staff knew how to make a safeguarding referral and would do so when appropriate. We also noted that feedback from safeguarding was included in staff meetings and daily staff huddles. Feedback was also shared by email to ensure all staff received it.

All staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. We saw multiple examples of patient notes being updated regarding their status and that the electronic record included any relevant safeguarding details. We also noted staff asking about family members who the patient may have caring responsibilities for.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. Mental Capacity Act training was incorporated into the mandatory training modules.

We did not observe any interactions that required restraint or restrictive practice but we were assured that these areas were covered within staff training and the appropriate policy.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them

Staff interacted with patients so that they understood their care and treatment, including finding effective ways to communicate with all patients including those with an identified impairment. Staff had access to the trust interpreter services that included video calls or translation services. A mobile language translation device could be wheeled to the patient to use when communicating with staff.

We saw examples of staff proactively encouraging patients to provide feedback on the service. Staff completed risk assessments for each patient on admission / arrival, using a recognised tool and reviewed this regularly, including after any incident.

Staff knew about and dealt with any specific risk issues such as possible sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. Following review of the sepsis audit we saw that between March 2025 and May 2025, the department achieved 82% compliance for sepsis management.

Compliance of SEPSIS treatment was audited and findings reported to the quality assurance committee. A clinical lead for sepsis was in post and a review against national SEPSIS guidelines was underway. However, the “Sepsis Management in Adults” guideline was passed its date of review of 1 January 2024.

The percentage of patients with symptoms of SEPSIS who received antibiotics within an hour at trust level in February 2025 was 67%. This increased to 77% in March, 79% in April and 88% in May 2025 demonstrating an improving trajectory across the trust.

There was an “Escalation of Acutely Unwell Patients” policy to support staff raising concerns about the patients condition. Managers told us that staff were assigned roles daily as part of the cardiac arrest team meaning that in the event of an emergency staff would respond appropriately.

We observed patient information leaflets were available in the department for patients with certain conditions on discharge explaining about their condition and worsening symptoms to look out for.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The paediatric area within the emergency department was not secure. Temporary escalation spaces used, such as the corridors, were not suitable for such care delivery. This was a breach of the good governance regulation.

The main emergency department comprised of 19 cubicles, 4 of which were in a designated resuscitation area, 9 the majors area and 6 were isolation rooms. There were also 2 mental health annex rooms, and 3 cots / beds in the paediatric bay. When the department was busy 10 temporary escalation spaces had been identified for patients to reside on a trolley in a corridor within the emergency department. Staff were designated to work in these areas when occupied by patients and completed an hourly patient monitoring checklist.

The patient waiting area was small, had no daylight, lacked appropriate seating and space to accommodate the amount of people attending the department. An internal barrier wall had recently been removed in the waiting area and changes made to seating and refreshment availability. However, we noted that the seating was fixed, could not be moved and there were only 20 seats available. There was no suitable seating for those who required adapted seating or adequate space for people accompanying patients. When the waiting area was full, those accompanying patients were asked to wait outside the department.

The triage window where patients were asked questions about their presenting condition was adjacent to the reception window. Patients were overheard when providing sensitive information history. Staff were aware of this and there was a room available for private conversations with patients if they wished to move to a more confidential environment.

Whilst there was a separate designated waiting area for paediatrics within the emergency department, it did not comply with the Royal College of Paediatricians emergency department guidance. This was because the paediatric waiting room was located off the main emergency department corridor with open access. Access to the area was not via secured doors. This was a potential safeguarding risk due to the location and lack of security in the paediatric area. Access to the paediatric bay door was via key pad, however, the door was held open during our onsite inspection.

The paediatric area was adjacent to the hub where patients with poor mental health conditions and challenging behaviours were cared for. Double doors between the areas were kept open. We observed a patient who had sustained a head injury walking freely into the paediatric area. A security guard was present, and we saw that staff needed to encourage the patient to return to the cubicle where he was receiving care. As a result, we escalated the risk of the doors being kept open to leaders during our inspection, who took action to close the doors.

The designated mental health assessment annex facilities were fully Psychiatric Liaison Accreditation Network (PLAN) compliant. However, we did observe there were points, including window fastenings and a hospital bed that could potentially be used to secure a ligature. In the event that these two rooms were occupied or patient need for medical intervention, there were two allocated cubicles, close to the central staff stations where patients could be continuously observed.

When the department was busy 10 temporary escalation spaces had been identified for patients use in a corridor within the emergency department. Staff were designated to work in these areas when occupied by patients and a "Seen and Safe" patient monitoring checklist completed hourly. One cubicle was kept free for patients to be taken for assessment and support with personal care. Temporary doorbells had been installed in the temporary escalation areas for patients to ring when they required the attention of staff.

Patients, including those on trolleys on the corridor, had access to call bells to request staff support. Emergency buzzers were present in the main patient areas. Oxygen was available either piped or in bottles. Suction was either adjacent to piped oxygen or portable, although the bay where patients could be seen, away from the corridor did not have piped oxygen. We were told there was a plan to add additional oxygen and suction in this bay.

The resuscitation area included four bays, one of which could be for isolation but was commonly used for seriously ill children and included a paediatric resuscitation trolley as well as posters appropriate for the care of acutely ill children.

There were a number of cubicles that were identified as an isolation area for patients who were at high risk of infection; these were separate from the main majors area.

The temporary escalation areas used posed a risk to patients. This was because the corridor was narrow, there was not enough room for patient trolleys to pass those on the corridor and turning spaces into rooms off the corridor was not sufficient. This resulted in patients on trolleys frequently being disturbed and knocked due to passing patients. The fire risk assessment, completed in December 2024, identified concerns regarding the ED corridors. The risk of fire had been identified with regards to electrical equipment blocking corridors as well as the means of escape being blocked with patients on trolleys. We were told that fire system improvements were planned, including updating the fire detection system and fire doors. However, this did not include proposed dates for completion. Staff were required to complete fire training, however compliance was below the trust target with medical staff at 66.7% and nursing staff at 83%.

The trust did not have oversight of when equipment was calibrated or checked to comply with manufacturer’s instructions. We requested details of routine maintenance of equipment used in the department; however, we only received a list of equipment as listed on an asset register. The information included that there was no work required, however there was no details of when equipment was last tested or routinely checked. Equipment that we reviewed during the onsite inspection had stickers that indicated their date for routine maintenance with all being within that date.

The service had appropriate plans and equipment for a major incident and business continuity, however we noted that some consumables were passed the expiry date. Trust staff acted on this and a plan was put in place to check future expiry dates.

The department managers were aware that the premises and environment were not suited to current patient need and had taken some action to improve the area. One of the reception desks, for checking in, was lower so those in wheelchair could see the reception staff; however, there was no hearing loop for those with a hearing impairment.

The same day emergency care (SDEC) area included consulting rooms with beds and comfortable chairs ranging from recliners to raised height and suitable for all.

There was a relatives’ room, with refreshments, where those close to patients who were acutely ill could wait away from the waiting room. The children’s bay was child-friendly with bright wallpaper and pictures as well as displaying health information such as measles. However, there was no play specialist employed to provide psychological support to families.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff training completion was below the trust’s target and concerns were raised about the number of staff available to care for patients within the department. This was a regulatory breach of safe staffing.

We spoke with a range of staff of all grades including nurses, doctors, students, assistant practitioners, pharmacy staff, care support workers, housekeepers, domestic staff, porters, security staff, receptionists, ward managers, and senior management. They reported staffing in the department was flexible and responsive to meet demand. The model was continuously reviewed and adapted in response to operational pressures, with an emphasis on skill mix and competency. Core staffing levels were determined by the Safer Nursing Care Tool for ED validated tool (SNCT). However, managers expressed concerns that the tool, was not reflective of their staffing needs for the volume and acuity of patients attending. Additional staff required to care for patients in temporary escalation places were not always available or staff drafted in from other areas across the hospital were who not always trained in the necessary skills required to work in the emergency department. Staff told us this put additional pressures on them as they were expected to undertake specialist care for larger groups of patients.

Between July 2024 and June 2025, the fill rate for registered nurses was an average of 91% per month and 88% for care support workers. The staffing tool did not indicate if registered nurses included paediatric staff. For the same period the average fill rate for paediatric staff was 81%.

The trust were aware paediatric staffing in ED was not compliant with the Royal College of Paediatrics and Child Heath (RCPCH) Facing the Futures Standards. A paediatric nurse was available for most shifts with a second paediatric nurse at peak times. However, due to the number of staff in post this was not always possible to achieve. Paediatric trained staff could be sourced from the paediatric ward or from the other hosptial site at Barrow in Furness which was 46 miles away.

There was a “Paediatric Nurse Staffing in the Emergency Department” standard operating procedure that included escalation process if not compliant with RCPCH Facing the Futures Standards. A paediatric emergency medicine (PEM) doctor was not employed, although a consultant had been nominated as paediatric liaison. There had been a previous secondment to the PEM post during winter months and there was a proposal that this be re-introduced next winter.

Between July 2024 and June 2025 the department staff sickness levels were:

• 5.31% medical staff
• 6.34% nursing staff.
• 11.02% minor treatment unit nursing staff
• 1.01% medical staff and 8.87% for nursing staff in SDEC

The trust average sickness level was 5.71% which was higher than the 5% national average.

Leaders covered staffing gaps with agency workers, and called in additional staff where possible, particularly during periods of high demand. There were gaps in medical staffing, between March 2025 and July 2025 not all shifts were covered. Between March 2025 and July 2025 of the 578 shifts that went out to bank, 44 were not covered. The trust filled 38 agency staff shifts between January 2025 and June 2025 for varying durations. Bank staff were given priority to fill any staffing gaps.

Between July 2024 to June 2025 in the department there was a turnover of:

• 2.99% doctors
• 2.96% nursing staff
• SDEC 38.71% doctors due to rotation of posts and 10.66% for nursing staff.

At the time of the inspection there were vacancies for a band 6 nurse, four band 5 nurses and one paediatric nurse.

Between July 2024 and June 2025, 325 incidents were reported relating to staffing levels and overcrowding in the department. One incident was graded as death with all others graded as either no injuries, low or near miss. There were no action plans in place that referenced learning from the reported incidents.

There had been changes to doctors’ rotas following feedback with consultants self-rostering. There was also designated roles and responsibilities for medical staff and job planning had improved. Senior medical staff assisted with training sessions in the department.

The mandatory training offer for staff was comprehensive and met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance. Trust overall compliance for training was 85% which was below the trust target of 90%. Training achievement in infection prevention and control, resuscitation, fire training and information governance were below the trust target. Basic life support training for medical staff was 66% and nursing staff 88%, advanced life support 87% for medical staff and 72% for nursing staff and paediatric life support was lower for nursing staff and medical staff.

The practice educators maintained oversight of training compliance levels with an action plan to improve uptake which included staff being allocated protected time to complete face to face training. A range of simulation activity took place to support the training offer for staff across the trust that were either adult or paediatric appropriate such as sepsis and trauma skills.

An external organisation was commissioned to deliver specialist mental health training virtually and compliance was 41%.

Overall appraisals compliance in the department was below required, at 81.8%. The trust target for appraisals was 90%. They were expecting to reach the target by October 2025.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were hand sanitisers, gloves, clinical sinks, clinical bins available, however we saw gloves discarded in the domestic waste. We observed gloves being worn for activities when not needed such as using computers. Sharps bins were not always dated or signed. We were told that the large yellow sharps bins were being phased out.

Staff completed mandatory training in infection prevention and control (IPC). Medical staff compliance was 88.9% for level 1, 63.9% for level 2 and 47.1% for aseptic non touch technique (ANTT). For nursing staff, compliance was 92.0% for level 1, 86.6% for level 2 and 61.5% for ANTT.

Infection prevention and control audits were routinely undertaken every 6 months unless required more frequently due to an outbreak or low compliance. In July 2025, the environmental audit compliance was 86.8% and the hand hygiene & personal protective equipment (PPE) audit compliance was 76.5%. An action plan was completed to address compliance levels including monitoring of training compliance, repeating audits weekly, and access to an infection prevention nurse (IPN) support daily in the department.

There were “Infection Prevention Monitoring and Surveillance” and “Infection Prevention Monitoring and Surveillance” policies. All areas were clean, had required furnishings and were well-maintained. Privacy curtains were unique for the department and disposable. We were told these were routinely changed every six months but more frequently if a deep clean was required. Domestic staff were very visible and part of the emergency department team. There was a sense of pride, and we observed constant cleaning. There were cleaning schedules in place and designated areas.

Commodes had I am clean stickers. All equipment in SDEC had I am clean stickers. Trolleys and equipment were cleaned between patients. Waiting room chairs were wipeable.

There were wipeable toys available in the playroom, however we did not see any being cleaned.

Between July 2024 and July 2025 there was one hospital onset healthcare associated (HOHA) case of Escherichia coli (e.coli) confirmed. The trust reported that there was no learning identified for the department as a result.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service made sure that medicines were handed safely. Checks to confirm people’s current medicine were made before prescribing, however in SDEC. A recent audit found people in ED did not always receive help to take pre-existing medication. Automated medicines cabinets had been implemented to aid with medicines security and oversight.

Our concerns identified meant that this was a breach of safe care and treatment.

People’s allergies and regular medicines were usually recorded in the emergency department (ED) and summary care records (SCR) were used to support this process. However, in a 2024 benchmarking audit the ED performed below national average for ‘staff helped to take pre-existing medication’ (Royal Lancaster Infirmary ED 62%, average 73%.) and for giving ‘sufficient information given on new medication’ (Royal Lancaster Infirmary ED 77%, average 92%). On occasion, although the prescriber’s we spoke with told us they viewed SCR and asked patients about their usual medicines, this was not always recorded before prescribing treatment in SDEC (same day emergency care).

The trust had identified a risk that patients seen in Same Day Emergency Care (SDEC) may miss doses of critical medicine if their care was transferred back to ED. This was because patients could not be transferred electronically but had to be discharged and readmitted to ED. Staff were managing this risk by telephoning ED to advise staff of the patient transfer, so that their medicines could be promptly prescribed. The trust had also identified the risk of a delay in administering critical medicines due to them not being prescribed in ED before admission as an inpatient. This was being monitored, with plans for a re-audit of compliance. Trust processes were in place for reporting and investigating medicines and controlled drugs incidents for review and learning. For example, we saw how a recent incident about medicines supply on discharge had been shared and discussed at an ED ward meeting.

We saw that patients received pain relief in a timely manner. The trust’s paediatric monthly audit of pain and vital signs showed decreasing compliance from 100% in January 2025 to 80% in June 2025 however, there was an uplift in performance in July 2025 to 96.4%.

The Patient Group Directions reviewed were in date and signed by relevant staff. PGDs are written instructions to facilitate the supply or administration of medicines to patients, without a prescription.

The emergency department had dedicated support from a pharmacy technician and/or a pharmacist (Monday to Saturday 8am to 5:30 pm, 5pm on a Saturday). The team focused on medicines reconciliation and identifying patients taking critical medicines, to help ensure that doses were not missed. The trust audited medicines reconciliation monthly. The audits showed decreasing performance from 61.3 % in February 2025 48.5 % in June 2025. There was an upturn in performance in July 2025 to 57.36%. This was because new automated medicine cabinets had been installed.

Risk assessments for venous thromboembolism (VTE) were completed promptly. However, should compression stockings stocking be advised, these were not available in ED. We were told these would be available when the patient moved to an inpatient ward.

The trust had a sepsis management policy, which staff working in the emergency department followed. The policy was overdue for review (review date January 2024). However, we were told that this was now in progress. The trust did not complete antimicrobial stewardship audits in ED but a sepsis audit was completed. This showed that that the percentage of patients who received antibiotics within 1 hour was below the 90% target but improving (combined audit across both hospitals) from 76.8% in March 2025 88.5% in May 2025. Data quality was recognised as a concern and steps were being taken to improve this, overseen by the trust deteriorating patient group.

The trust was implementing electronic medicines cupboards, to help support the secure storage and audit of medicines handling. Trust audits showed compliance with the safe and secure handling of medicines audit standards. We did see one area where stock checks had not been completed for the previous month. The trust put actions in place to address this. Controlled drugs handling audits showed an improving performance, with current compliance at 78.8% in July 2025 against a trust target of 90%. Controlled stationary such as paper prescriptions were stored securely and monitored to ensure they were handled in line with trust policy. The required antidotes were available and regularly checked by pharmacy staff.

For patients who presented with a mental health condition, there was a concern that prescribed medicines could potentially be missed due to the collaboration of two NHS trusts.